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FORM FOR REPORTING SOCIAL WORK CONTINUING …

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January 15, 2015 This form is only for use when a CONTINUING education provider does not provide a certificate of attendance. FORM FOR REPORTING SOCIAL work CONTINUING EDUCATION Name of Licensee ______________________________________Li cense Licensee's Address ________________________________________ __________________________ Title of Session_________________________________ ____________________________________ Sponsor ________________________________________ __________________________________ Date(s) & Time of Attendance ________________________________________ ________________ Amount of Credit Received ________________________________________ __________________ Actual time spent in session The instructor, sponsor, leader, training coordinator, or agency director must sign below attesting to attendance. ________________________________________ ___ ___________________________________ Name & Credentials (typed or printed) Signature NOTE TO LICENSEE: Licensees must maintain verification of attendance at all CONTINUING education workshops.

January 15, 2015 This form is only for use when a continuing education provider does not provide a certificate of attendance. FORM FOR REPORTING SOCIAL WORK CONTINUING EDUCATION

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